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Federal HIV/AIDS Funding What’s Been Done, Where We Are, and What’s Next?

USCA 2019 Washington, DC September 7th, 2019

Workshop Outline

• Presentation
• The Current Budget Situation
• Appropriations Update
• Next Steps
• Panel Discussion
• HIV Prevention
• Ryan White HIV/AIDS Program
• Minority AIDS Initiative
• Viral Hepatitis Prevention
• Housing
• HIV/AIDS Research
• Sex-Ed Programs
• STD Prevention

The Current Budget Situation

Carl Schmid Deputy Executive Director The AIDS Institute

FY 2018 Federal Budget - $4.1 Trillion

Source: Congressional Budget Office

Mandatory Spending $2.5 Trillion 61% Discretiona ry Spending $1.3 Trillion 31% Net Interest $325 Billion 8%

Defense $623 b 15% Nondefense $639 b 16% Other $570 b 14% Medicaid $389 b 9% Medicare $582 b 14% Social Security $982 b 24% Net Interest $325 b 8%

FY 2018 Discretionary Spending $1.3 Trillion

Source: Congressional Budget Office

Total Deficits and Surpluses

Source: Congressional Budget Office

CBO Projects $12.2 trillion deficit by 2029

Source: Congressional Budget Office

Federal Debt Held By the Public

Projected Government Spending

Source: Congressional Budget Office Note: Projections were made prior to the FY2020 and FY2021 budget agreements and do not take into account increased spending caps

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Appropriations Update

Nick Armstrong Policy Associate The AIDS Institute

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Appropriations 101 Key Terms

• Discretionary Spending – funding that is subject to the annual appropriations

process

• Mandatory Spending – funds automatically spent based on law and not subject to

Congressional approval (Medicare, Social Security, etc.)

• Appropriations Bills – laws passed by crafted and passed by Congress that legally
• bligate funding levels for discretionary programs
• Labor-HHS (L-HHS) Bill – one of 12 appropriations bills passed by Congress which

funds the Depts. of Labor, HHS and Education

• Mark-Up – Committee meetings where Congress reviews details of a bill, offer and

debate changes, and vote to advance a bill to the next legislative step

• Fiscal Year – yearly cycle of funding starting Oct. 1st and ending Sept. 30th

President’s Budget

Budgeting

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Appropriations 101 How the process (theoretically) works

President’s Budget

• Statement of

policy

• No effect of law

Congressional Action

• 12 Appropriations

Subcommittees

• Full Committee
• Chamber votes

Conference

• Negotiate

differences

• Conference bill

crafted

• Chamber votes

Final Bill(s) Signed

Trump’s Proposed FY19 Budget Cuts

• Proposed cuts

– CDC HIV Prevention: -$40 m – CDC STD Prevention: -$5 m – NIH AIDS Research: -$89 m – HOPWA: -$45 m

• Proposed Program Eliminations

– Ryan White AETCs: -$34 m – Ryan White SPNS: -$25 m – SAMHSA Minority AIDS Programs: -$116 m – Minority HIV/AIDS Fund: -$54 m – Teen Pregnancy Prevention Program: -$101 m

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Congressional Response

• House and Senate level funded most domestic HIV

programs

• House

– Opioid Related Infectious Diseases: +$20 m – HOPWA: +$18 m – Proposed Program Eliminations

• Teen Pregnancy Prevention Program: -$101 m
• Title X Family Planning: -$286 m

– “Sexual Risk Avoidance” Abstinence-Only: +$5 m

• Senate

– Opioid Related Infectious Diseases: +$5 m – “Sexual Risk Avoidance” Abstinence-Only: +$10 m

Fiscal Year 2019

• Trump FY19 Budget – Feb. 2018
• Senate Passes L-HHS Bill – June 2018
• House Passes L-HHS Bill – July 2018
• President signs Minibus Appropriations Bill – Sept. 2018
• Two Continuing Resolutions passed
• Partial government shutdown

– Dec. 22, 2018 to Jan. 25, 2019 – House switches from Republican to Democratic control

• Final Appropriations passed Jan. 25, 2019

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Final FY19 Appropriations

• Increases

– CDC STD Prevention: +$5 m – Opioid Related Infectious Diseases: +$5 m – HOPWA: +$18 m – NIH Total: +$2 b

• No proposed cuts were included in the final bill
• Most domestic HIV/AIDS programs level funded

– $10 m increase to “Sexual Risk Avoidance” Abstinence-Only Programs

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FY 2019 Takeaways

• There was bipartisan cooperation for L-HHS

programs

• L-HHS was passed with Defense, which prevented

health programs from being impacted by the shutdown

• Congress did not have to address Budget Caps –

allowing for efficiency in the appropriations process

• Proposed cuts to domestic programs were less

severe than previous years

• Advocacy against proposed cuts was effective

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FY2020 – A Unique Opportunity

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we do support the administration’s plan to reduce HIV transmission 90 percent in 10 years. So, we include the administration’s request for $120 million for programs through Health Resources and Services Administration to increase access to the ground- breaking HIV drugs and $140 million for CDC’s work in HIV outreach and disease we go even further. We provide an additional $46 million for the Ryan White program. We provide additional funds for the Minority AIDs initiative. And, we provide an additional $150 million for NIH’s HIV research to secure a vaccine or a cure.

President’s FY2020 Budget

The Ryan White HIV/AIDS Program

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FY2019 Final FY2020 President’s Request FY2020 House Part A $655.9 m (+$0.0 m) $655.9 m (+$0.0 m) $677.5 m (+21.6 m) Part B: Care $414.7 m (+$0.0 m) $414.7 m (+$0.0 m) $419.6 m (+$4.9 m) Part B: ADAP $900.3 m (+$0.0 m) $900.3 m (+$0.0 m) $912.0 m (+$11.7 m) Part C $201.1 m (+$0.0 m) $201.1 m (+$0.0 m) $207.6 m (+$6.5 m) Part D $75.1 m (+$0.0 m) $75.1 m (+$0.0 m) $76.0 m (+$0.9 m)

The Ryan White HIV/AIDS Program

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FY2019 Final FY2020 President’s Request FY2020 House Part F: AETCs $33.6 m (+$0.0 m) $33.6 m (+$0.0 m) $34.0 m (+$0.4 m) Part F: Dental $13.1 m (+$0.0 m) $13.1 m (+$0.0 m) $13.3 m (+$0.2 m) Part F: SPNS $25.0 m (+$0.0 m) $25.0 m (+$0.0 m) $25.0 m (+$0.0 m) Ending the Epidemic Plan N/A +$70.0 m +$70.0 m

Centers for Disease Control

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FY2019 Final FY2020 President’s Request FY2020 House Division of HIV/AIDS Prevention Total $788.7 m (+$0.0 m) $928.7 m (+$140.0 m) $945.6 m (+$156.9 m) HIV Prevention $755.6 m (+$0.0 m) $755.6 m (+$0.0 m) $755.6 m (+$0.0 m) Ending the Epidemic Plan N/A +$140 m +$140 m School Health $33.1 m (+$0.0 m) $33.1 m (+$0.0 m) $50.0 m (+$16.9 m) Viral Hepatitis $39.0 m (+$0.0 m) $39.0 m (+$0.0 m) $50.0 m (+$11.0 m) STD Prevention $157.3 m (+$0.0 m) $157.3 m (+$0.0 m) $167.3 m (+$10.0 m) TB Elimination $142.2 (+$0.0 m) $135.2 (-$7.0 m) $152.3 m (+$10.1 m) Opioid Related Infectious Diseases $5.0 m $58.0 m (+$53.0 m) $35.0 m (+$30.0 m)

National Institutes of Health

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FY2019 Final FY2020 President’s Request FY2020 House Total $39.1 b (+$2.0 b) $33.0 b (-$6.1 b) $41.1 b (+$2.0 b) AIDS Research $3.045 b (+$45.0 m) $2.621 b (-$423.9 m) $3.200 b (+$155.0 m)

Minority AIDS Initiative Programs

FY2019 Final FY2020 President’s Request FY2020 House

Minority HIV/AIDS Fund $53.9 m (+$0.0 m) $53.9 m (+$0.0 m) $65.0 m (+$11.1 m) SAMHSA $116.0 m (+$0.0 m) $116.0 m (+$0.0 m) $121.0 m (+$5.0 m)

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Housing Opportunities for Persons with AIDS

FY2019 Final FY2020 President’s Request FY2020 House

HOPWA

$393.0 m (+$18.0 m) $330.0 m (-$63.0 m) $410.0 m (+$17.0 m)

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Sex-Ed & Family Planning Programs

FY2019 Final FY2020 President’s Request FY2020 House

Title X

$286.5 m (+$0.0 m) $286.5 m (+$0.0 m) $400.0 m (+$113.5 m)

Teen Pregnancy Prevention Program

$101.0 m (+$0.0 m) $0.00 (-$101.0 m) $110.0 m (+$9.0 m)

“Sexual Risk Avoidance” Abstinence-Only Program

$35.0 m (+$10.0 m) $0.0 m (-$35.0 m) $0.0 m (-$35.0 m)

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Total Domestic HIV Programs

FY2019 Final FY2020 President’s Request FY2020 House

$7.059 b $6.903 b (-$156 m) $7.641 b (+$582 m)

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we do support the administration’s plan to reduce HIV transmission 90 percent in 10 years. So, we include the administration’s request for $120 million for programs through Health Resources and Services Administration to increase access to the ground- breaking HIV drugs and $140 million for CDC’s work in HIV outreach and disease we go even further. We provide an additional $46 million for the Ryan White program. We provide additional funds for the Minority AIDs initiative. And, we provide an additional $150 million for NIH’s HIV research to secure a vaccine or a cure. “The HIV epidemic still plagues our Nation, with more than 38,000 Americans infected every year. In response, my Budget provides $291 million to the Department of Health and Human Services to defeat the HIV/AIDS epidemic.”

• President Trump’s FY2020 Budget

“We do support the administration’s plan to reduce HIV transmission 90 percent in 10

• years. So, we include the administration’s request for $120 million for programs

through Health Resources and Services Administration to increase access to the ground-breaking HIV drugs and $140 million for CDC’s work in HIV outreach and disease monitoring. But, we go even further.”

• Rep. Rosa DeLauro, Chairwoman

House L-HHS Appropriations Subcommittee

House Report Language

• Completely removes prohibition

against using funding for syringe service programs (SSPs)

– Funding can be used to purchase syringes

• HIV Research at NIH must be

increased proportional to overall NIH funding increases

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House Report Language Cont.

• EtE Initiative Language

–Directs HHS Secretary to submit multi-year plan to Congress –Report to Congress on Initiative progress, out year cost estimates

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Bipartisan Budget Agreement

• Budget Control Act set caps on FY20 spending levels

– Appropriations beyond the caps would result in across the board cuts, or sequestration

• Democrats did not want cuts to non-defense programs, Republicans

did not want cuts to defense programs

• In order to fund both party’s priorities, agreement to raise caps was

needed

• Initially, White House was not in favor of a budget agreement
• Negotiations led to new budget caps and raising of debt limit for 2

years

• Budget Agreement signed into law August 2nd

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Bipartisan Budget Agreement

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FY2019 FY2020 Enacted Budget Control Act President’s Budget Budget Agreement Defense Caps 716 576 (-140) 576 (-140) 738 (+22) Non-Defense Caps 605 543 (-62) 543 (-62) 632 (+27) (In billions of dollars)

Where are we now?

• House of Representatives

– Appropriations Committee finished work on all appropriations bills – House passed most bills, including L-HHS and T-HUD

• Senate

– Has yet to mark-up any appropriations bills

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The Appropriations Process What’s next?

• FY 2019 funding ends on Sept. 30th

– Congress must pass funding bills or Continuing Resolution in order to avert government shutdown

• Senate still needs to release 302(b) allocations
• Senate options

– Couple L-HHS with Defense to promote quick passage – Go directly to conference on L-HHS bill and not consider it in the Senate – Consider L-HHS as a standalone bill, but pass CR in order to allow time for conferencing

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The Appropriations Process What’s next?

• Continuing Resolution

– November or December

• Anomalies

– A CR level funds all programs for a set amount of time to allow for Congress to pass new appropriations bills – Anomalies allow for adjustments for certain programs that may need changes in funding within the CR window – Administration sent the “Anomalies List” to Congress which included all funding for the Ending the HIV Epidemic Initiative

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Political Considerations

• House and Senate are controlled by two different

parties with separate priorities

• House bill funds non-defense programs above

new FY20 caps, requiring revisions to the bills

• President Trump continues to prioritize wall

funding

– Could jeopardize ability to have bills signed into law

• Senate will not pass bills with policy riders
• Government shutdown was extremely unpopular
• Short timeline and other policy priorities

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What We are Doing as Advocates

• The AIDS Budget and Appropriations

Coalition (ABAC)

– Over 110 member organizations – Advocates for adequate resources for domestic HIV/AIDS programs across the federal government

• Partnership to End HIV, STDs and

Hepatitis

– The AIDS Institute, AIDS United, NMAC, NASTAD, NCSD – Brownstein Hyatt Farber Schreck

• Other Coalitions

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What We are Doing as Advocates

• Sign-on letters to the Administration and Congress
• Worked with House and Senate offices to organize

“Dear Colleague” Letters

• Organized meetings with House and Senate offices

and HIV/AIDS community leaders

• Submitted testimony to Appropriations Committees
• Submitted questions to Appropriators to ask

Administration Officials

• Worked with offices to propose successful

amendments

• Social media campaigns

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Panel and Discussion

Mike Weir NASTAD Jenny Collier Ryan White Medical Providers Coalition Ernest Hopkins SF AIDS Foundation Sam Cyrulnik-Dercher SEICUS Lauren Killelea National AIDS Housing Coalition Frank Hood The AIDS Institute Elizabeth Lovinger Treatment Action Group Taryn Couture NCSD

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What Can You Do?

• Engage with your Representatives

– Tell them your story and the importance of these programs – Invite them to visit your organization – Thank Members who have been our champions – Emphasize the unique opportunity to end the epidemic

• Join the AIDS Budget and Appropriations Coalition

– Up to date resources and news – Monthly calls – Information on Hill meetings

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Resources

• AIDS Budget and Appropriations Coalition

– http://federalaidspolicy.org/category/abac/

• Partnership to End HIV, STDs and Hepatitis

– http://endhivstdhep.org/

• Opioid and Health Indicators Database

– http://opioid.amfar.org/

• Find Your Representative

– https://www.house.gov/representatives/find/

• CBPP: Introduction to the Federal Budget Process

– https://www.cbpp.org/research/policy-basics-introduction-to-the-federal-budget- process

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Like, Love, Share!

@AIDSadvocacy Facebook.com/TheAIDSInstitute

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Thank you!

Nick Armstrong Policy Associate The AIDS Institute narmstrong@theaidsinstitute.org

Presentation is available online at: http://www.theaidsinstitute.org/USCA2019

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